2026 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals
Page 57

 

Benefit Description

Orthopedic and Prosthetic Devices (cont.)
 
  • Shoes (including diabetic shoes)
     
  • Over-the-counter orthotics
     
  • Arch supports
     
  • Heel pads and heel cups
     
  • Wigs (including cranial prostheses), except for scalp hair prosthesis for hair loss due to the treatment of cancer, as stated above
     
  • Over the counter hearing aids, enhancement devices, accessories or supplies (including remote controls and warranty packages), and hearing aids when prior approval was not obtained


Standard Option - You Pay
All charges

Basic Option - You Pay
All charges

 

Benefit Description

Durable Medical Equipment (DME)
Durable medical equipment (DME) is equipment and supplies that are:
 
  1. Prescribed by your attending physician (i.e., the physician who is treating your illness or injury);
     
  2. Medically necessary;
     
  3. Primarily and customarily used only for a medical purpose;
     
  4. Generally useful only to a person with an illness or injury;
     
  5. Designed for prolonged use; and
     
  6. Used to serve a specific therapeutic purpose in the treatment of an illness or injury.

We cover rental or purchase of prescribed durable medical equipment, at our option, including repair and adjustment. Covered items include:
 
  • Home dialysis equipment
     
  • Oxygen equipment
     
  • Hospital beds
     
  • Wheelchairs
     
  • Crutches
     
  • Walkers
     
  • Continuous passive motion (CPM) devices
     
  • Dynamic orthotic cranioplasty (DOC) devices
     
  • Insulin pumps
     
  • Other items that we determine to be DME, such as compression stockings

Note: We cover DME at Preferred benefit levels only when you use a Preferred DME provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred DME providers.


Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Basic Option - You Pay
Preferred: 35% of the Plan allowance

Participating/Non-participating: You pay all charges

 

Durable Medical Equipment (DME) - continued on next page